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Citation:Vorobyeva O.V. Stress and adaptation disorders // RMW. 2009. №11. P. 789.
Stress, anxiety and depression are meaningful factors in the development and progression of a large number of diseases - from asthma, cardiovascular disease to cancer and HIV infection. This connection between stress and neurobiological changes, leading to mental disorders and somatic violations, is perfectly documented in the medical literature over the last century.
Stress (eng. Stress - voltage) is a state of voltage of adaptation mechanisms. The concept of "stress" was first described T.R. Glynn in 1910 and thanks to the classical work of H. Selye (1936) firmly entered in everyday life. Stress in a broad sense can be determined as a non-specific response of the body into a situation that requires a greater or less functional restructuring of the body corresponding to adaptation to this situation. Not only negative events, but also psychologically favorable events require adaptive costs and, therefore, are stress.
It is important to keep in mind that any new life Si-Tuition causes stress, but far from each of them would be critical. Critical situations cause di-stress, which is experiencing as a mountain, misfortune, the use of forces and is accompanied by a violation of adaptation, control, prevents personality self-actualization. All critical situations, from relatively lungs to sashes difficult (stress, frustration, conflict and crisis), require a person of various internal work, certain skills to overcome and adapt to them.
The degree of severity of the reaction to the stress of the same force may be different and depends on many factors: the floor, age, personality structure, the level of social support, various circumstances. Some people with extremely low stress resistance in response to a stress event that does not go beyond the usual or everyday mental stress may develop a painful state. More or less obvious to patient stressful events cause painful symptoms that violate the usual functioning of the patient (professional activities, social functions may violate. These painful conditions received the names of the adaptation disorder.
Clinical picture
The disease is developing, as a rule, within three months after the impact of a psychosocial stressor or multiple stress. Clinical manifestations of adaptive disorder are extremely variable. Nevertheless, it is usually possible to allocate psychopathological symptoms and vegetative disorders conjugate with them. It is the vegetative symptoms that make a patient look for help from a doctor.
The feeling of heat or cold, tachycardia, nausea, AB-up to-mining pain, diarrhea and constipation can be in a factor of a vegetative response to stress. Inadequate incentive (stress) Vegetative response - basis for many psychosomatic disorders. Knowledge of a pattern of a vegetative response to psychological stress makes it possible to understand stress-dependent diseases (Table 1). A vegetative response to stress may be a trigger of a somatic disease (psychosomatic bo-lez-n n). For example, a cardiovascular response to stress increases the consumption of oxygen myocardium and can cause angina in persons with coronary disease.
Most patients make exclusively organ complaints based on their own or cultural ideas about the importance of a particular organ in the body. Vegetative disorders can manifest themselves mainly in one system (more often in cardiovascular), but in most cases an active patient abstract allows you to identify less pronounced symptoms from other systems. With the course of the disease, vegetative disorders acquire a distinct polysishemistry. A natural dysfunction for vegetative dysfunction is the replacement of some symptoms to others. In patients, in addition to vegetative dysfunction, sleep disorders are quite often noted (sleeping, sensitive surface dream, night awakening), asthenic symptom complex, irritability, neuroendocrine disorders.
Mental disorders are bonded to accompany vegetative dysfunction. However, the type of mental expansion and the degree of its severity varies widely from various patients. Mental symptoms are often hidden behind the "facade" of massive vegetative dysfunction, are ignored by the patients and those surrounding it. The ability of the doctor "see" in the patient, in addition to vegetative dysfunction, psychopathological symptoms are decisive in the diagnosis of adaptation disorders.
Most often, disadaptation is characterized by anxious mood, the feeling of the inability to cope with the situation and even decrease in the ability to function in everyday life. Anxiety is manifested by diffuse, extremely unpleasant, often an indefinite feeling of the fear of something, feeling a threat, a sense of voltage, increased irritability, fusibility (Table 2). The patient experiences anxious premonition - a future-oriented concern, which reflects the readiness to cope with the upcoming negative events. Sometimes the patient makes concerns about real and / or alleged unpleasant events. For example, such a patient may express various catastrophic thoughts associated with the global economic crisis: "... And for the spring in our country, everyone will eat solely with black bread and water. And there will be no cars on the street - nothing will be refilled. Pre-put - empty streets ... ". If the listener also spinning to anxiety, the patient's words fell to blast soil, anxiety begins to cover the patient's environment. Such dissemination of anxiety is especially characteristic of the periods of social disadvantaged. At the same time, anxiety in this category of patients can manifest themselves with specific fears, primarily concerns about their own health. Patients experience fear of possible development of stroke, heart attack, oncological process and other severe diseases. This category of patients is characterized by frequent visits to the doctor, carrying out numerous repeated instrumental research, careful study of medical literature.
The disorder of adaptation with depressive on-stroke is characterized by a reduced background of the structure, sometimes reaching the level of longing, limiting the usual interests, desires. Patients express dog-simistic thoughts regarding current events, negatively interpreting any events monotonously, blame themselves and / or those surrounding in the inability to influence the events. The future seems to be solely in black colors. For this category of patients, mental and physical exhaustion, a decrease in the concentration of attention, worsening memory, loss of interests is characteristic. Patients pay attention to that it is difficult for them to collect thoughts, any undertaking seems impracticable, a volitional effort is required to maintain ordinary household activity. The difficulty of concentrating attention on one question, the difficulty in making decisions, and then in incarnation to life. Patients, as a rule, are aware of their inconsistency, but they try to hide it, leading a variety of reasons for the justification of their inaction. The main symptom of depression is a reduced mood (longing) is often actively negotiated by the patient or is considered as an insignificant secondary symptom associated with somatic pathology. In some cases, depressive affect may be hidden behind additional mental symptoms: irritability, hypochondriac, anxiety, phobic symptoms. More than half of patients with adaptation disorders do not realize that they suffer from mental disorder, and only somatic complaints are presented. When attempting a doctor to discuss the patient's mental experiences, the latter almost always deals with a negative reaction. These patients are usually extremely sensitive to any hints for "unreasonable" of their complaints, so all issues related to the mood and other mental symptoms should be set in an exceptionally friendly manner. It is meaningless to argue with such patients, besides, it can injure them. The narrowing of the circle of interests and loss of pleasure (the second most important symptom of depression) can also be ignored by patients; Or certain life limitations are considered by him as the inevitable consequence of a somatic disease. In such cases, an objective information from close relatives is needed to understand the causes of the patient's deadaption.
The most important stage (positive) diagnosis of disadaptation in general general practices is to identify the characteristic features of complaints related to depression and their characteristic environment. Soma-Tosh complaints, pathogenetically associated with depression and anxiety, are primarily characterized by polymorphism, variability, contradictory (from-day-a logical clinical connection between complaints). Patients having inexplicable somatic symptoms must first be considered as a risk group with respect to adaptation disorder. Especially high risk in patients who have several somatic symptoms, regarding their condition, as very poor in the absence of objective organic pathology. These patients tend to talk about the feeling of dissatisfaction after a visit to the doctor, and it is precisely such patients who doctors are most often regarded as "difficult." Most often, these complaints are manifestations: 1) vegetative dysfunction (mainly in the cardiovascular system, gastrointestinal tract, respiratory system); 2) chronic pain syndrome (cardialgia, cepalgia, back pain); 3) hysterical disorders (com in throat, tremor, dizziness, gait violation, senthenetics paresthesia). Specially studied studies have shown that, in addition to the urgent ("organ"), the following violations are most often observed for a patient:
. Disssony (and the classical "morning insomnia" with characteristic early awakens, there may be difficulties of falling asleep, superficial sleep or hypersime, not bringing the feelings of morning cheerful);
. a sense of pronounced fatigue, which is already preceded by mental or physical on-load;
. irritability, gridness, reduced self-esteem, feeling of pity for yourself, sense of hopelessness, exaggeration of gravity of a real somatic disease;
. difficulties if necessary, to focus attention, which may be regarded by a patient as a memory violation;
. Sexual dysfunctions, most often a decrease in Lee Bi-to
. Change of appetite (lack of appetite / increased appetite) with weight change by more than 5% per month;
. Health care, accompanied by unpleasant bodily sensations, indefinitely bad premonitions with the peak of symptoms in the morning hours;
. The rejection of the negative results of physical examinations.
Described depressive symptoms surrounding topical complaints, it is necessary to identify with the help of an active question, since, as a rule, it is difficult to verbally express their mental state and they "prefer" to describe the doctor only understandable somatic sensations.
Many of the described accompanying symptoms relate to motivational disorders in patients with disorders of adaptation with alarming and / or depressive mood. This is the predominance of a feeling of fatigue, weakness, disorders of food behavior (oscillation of appetite, including within 24 hours). Ni-necks can manifest themselves to falling asleep, up-speed sleep with frequent awakening, frightening dreams, early awakening with a sense of inexplicable anxiety, dissatisfied with a dream and lack of a feeling of rest after sleep. Violations in the field of intimate relationships in men-gut manifest itself premature ejaculation and secondary decrease in libido; In women - a decrease in the frequency and degree of orgasm, as well as interest in sexual life.
All the above disorders are often not evaluated as somatic manifestations of stress, and even more enhance the feeling of helplessness. The last silent symptoms are social deadaptation. Patients begin to cope poorly with the usual professional activities, they are pursued by professional failures, as a result of which they prefer to avoid professional responsibility, refuse to occupy professional growth. A third of patients fully terminate professional activities. Communicative violations make it difficult for conventional social activity, lead to conflicts in personal life (Table 3).
Currently, diagnostic criteria for adaptation disorders (Table 4) are proposed. In the ICD-10, close disorders are referred to as disorder of adaptive reactions (F43.2).
Characteristics of stressors
Factors and response
Stressful events causing disordate disordiction are events that do not reach quantitative and qualitative characteristics of emergency stress, but the necessity of psychological adaptation. Most often, patients point to conflicts in interpersonal relationships, in particular, marital conflicts, divorce, travel, as well as service issues. Women are painfully reacting to stressful events in private life, and for men, professional failures are the most significant factor. Individual disease can be a significant stress factor regardless of gender. The consequences of the disease, possible disability, the threat of pain, severe disability, concerns to become a heavy burden for family members can lead to the development of a deadaptive disorder requiring a doctor's intervention.
The growth of psychopathological manifestations and somatic violations in the turnover years of the development of society testifies to the pathogenic influences of public social factors on health. "Improtected environmental pressure", an unstable society that makes increased regulations for people becoming chronic stressors. A constant threat, coming from the surrounding world, and the inability of a person to cope or manage future negative events leads to distress alarm and vegetative activation. Some researchers even identify social and stress disorders. For the first time, the term "social disease" was proposed by A.M. RO-Zenstein in 1923. Since then, the pathogenic role of social stressors is convincingly proven. It is necessary that stress threats more often causes anxiety reactions, and the stress of loss is depressive.
Important factors in the development of adaptive disorders are the number of stresses and their individual importance. It is well known that with an equal stress level, some people are ill, and others are not. Currently, the factors predispose to the development of the disease in response to stress are known. Such factors include personality characteristics of human, protective mechanisms and strategies to confront stress, as well as the presence or absence of social support. The preliminary prognostic assessment of the personality of the stress event is also important. An exceptionally negative assessment of the stressful event and the exaggeration of danger is caused by greater harm.
Psychological or biological stress causes a normal (physiological) response of the body in the form of a psycho-physiological reaction, manifested by anxiety symptoms and vegetative dysfunction, which is due to a cascade of neuroendocrine changes. In response to stress from the hypothalamus, corticotropin-rilizing factor (CTRF) is distinguished, which stimulates the front share of the pituitary gland, where the ATG has begins to be strongly synthesized. ACTH, in turn, stimulates the release of glucocorticoids (cortisol) from adrenal cortex. The sympathetic nervous system is activated with all the forms of stress, while, among other things, adrenaline is allocated from the brainstanding agents to the blood, which serves as an active stimulant secretion of the ACTH pituitary gland and enhances the effect of other mechanisms activating the pituitary function during stress (Table 5). Normally, these processes will soon cease, since the hypothalamic-pituitary-no-above - the reader system is regulated by the feedback mechanism. Glucocorticoid receptors of the front lobe of the pituitary gland play a key role in the braking of hypothalamic-pituitary-sensitive SIS-TE-we and the further secretion of glucocorticoids in stress conditions.
This psychohegetative answer is very important to overcome an acute physical threat. But in modern society, stress more often has a psychosocial nature, and such a type of response causes, rather, harm than the benefit of health. Modern society is characterized by a rapid flow of life, an abundance of information, the requirement of high productivity, efficiency, constant competition, a decrease in the share of heavy physical work, a lack of time and opportunity for recreation and recovery. Increased load on the nervous system, mental overwork. Insufficient rest and recovery causes greater harm than the absolute level of stress. Previous traumatization plays a special role.
Chronic psychosocial stress even low intensity prolongs changes caused by acute stress, causing a long-term ACTG-MU-Muzeniya and the depletion of adrenal cortex. For example, under conditions of uncontrolled protracted stress, healthy volunteers have an increase in the plasma concentrations of norepinephrine and ACTH. On the other hand, premorbide also affects the occurrence of adaptive disorders. Presumably breakdown in the reverse mechanism of braking secretion of glucocorticoids leads to protracted psychophysiological re-accommodation for stress. It is possible that patients with anxiety and / or depression there is a certain defect in the feedback mechanism. At the very least, there are convincing evidence that a certain psychobiological vulnerability characterized by a supercount neurobiological response to life stresses is peculiar to anxiety. Clinical alarm when strengthening this vulnerability or severity of current stressful factors can progress to depression. Pato gene-called the role of everyday stress begins to manifest themselves with its long-term exposure to persons with low stress availability, which have such personal features as nihilism, anxiety, social alienation, non-sufficiency that have insufficient social support. Especially pathogenic is stress during the periods of hormonal and psychophysiological restructuring (Pubertat, beginning of sex life, pregnancy and childbirth, abortion, menopause).
The line between the "normal" response to stress and pathological anxiety disorder is often very blurred and a person is difficult to understand when it is necessary to seek professional help. These subsidarial disturbing disturbances are most difficult for diagnosis, often remain untreated, while having an extremely negative impact on the quality of life of the patient and those surrounding it. At least, you should consult a doctor when concern about everyday events is not controlled. For example, when, in addition to nervousness, fussiness, impaired concentration, irritability, there is a sleep disorder, dizziness, tachycardia, epigastric discomfort, dry mouth, sweating, headache, chills and other symptoms of vegetative dysfunction.
Treatment
Despite the bondability of vegetative dysfunction and often masked character of emotional disorders, the basic method of treating adaptation disorders is psychopharmacological treatment. The therapeutic strategy must be built depending on the type of dominant disorder and the degree of its severity. The choice of drug depends on the degree of severity of the level of anxiety and the duration of the disease.
If painful symptoms exist short time (up to two months) and slightly violate the functioning of the patient, then they can use both drugs (anxiolytic therapy) and irritable methods. Nick-therapy is, first of all, the possibility of you-ray patients with your fears in the situation of psychological support that the doctor can have. Of course, the professional assistance of a psychologist can activate the adaptation methods characteristic of the patient.
Medicinal treatments include primarily tranquilizing drugs. Benzodiazepi-no-orxiolitics are used to relieve acute alarm symptoms and more than 4 weeks should not be applied due to the threat of the formation of dependence syndrome. With a short-term subsidarial or soft alarming disorder of adaptation, plant soothing fees or preparations based on them, antihistamines (hydroxyzine) are used. For many years, Valerian has been used in traditional medicine due to hypnotic and sedative effects and to date remains very popular medicine. Preparations containing valerian and additional phyto extracts, enhance the anxiolytic effect of Valerians, were particularly successful. The wide application found a drug percene, which contains, in addition to Valerians, Melissa and Mint extract, which enhances the anxiolytic effect of valerian and adds antispasmodic effect. Oso-Ben - but well established itself in the treatment of subsindrome alarming and soft disturbing disorders of Persen-Forte, co-der-producing 125 mg of Valerian extract in a capsule against 50 mg in tableted form, so that Per-Saint-Forte provides high and fast Anxio -Lectic effect. The spectrum of the application of per-hay-form-those in the practice of clinician is extremely wide - from use in monotherapy for the treatment of subsidommal and soft disturbances to a combination with antidepressants for alarm leveling for anxiety-depressive disorders. There are no clear recommendations on the duration of the therapy of soft and subsidarial alarm syndromes. Nevertheless, most studies have proven the benefits of long course therapy courses. It is believed that after the reduction of all the symptoms, at least 4 weeks of medicinal remission should pass, after which an attempt is made to cancel the drug. On average, the treatment of sedative races is 2-4 months.
Preparations of the first queue of choice for the treatment of chronic alarm disorders are selective inhibitors of serotonin reverse seizure (SSRS). In case of adaptation disorders, the question of on-knowledge SSIRS rises in the case of the risk of disorder (progression of symptoms for more than three months) and / or risk of adaptive disorder in the clinical form of psychopathology. In addition, the indication for the appointment of antidepressants is an adaptation disorder with an alarm-depressive mood or the dominance of depressive mood.
Many drugs used to treat mood disorders, anxiety and sleep disorders can be poorly to be patients due to side effects, which ultimately level their effectiveness. Official preparations of vegetable origin, having significantly less side effects, can be considered as an alternative therapy or used to enhance the effectiveness of prescription drugs (in particular, in the intolerance to tranquilizers and antidepressants).
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GOU DPO "St. Petersburg Medical Academy of Postgraduate Education"
Department of Child Psychiatry, Psychopathy and Medical Psychology
Theme of abstract:
Adaptation disorders. Somatoform disorders
Artist: Stolnikova Yu.N.
Place of work: GUZ
"Regional psychoneurological
Hospital number 5 "
Magnitogorsk, 2008.
Introduction
The whole history of psychiatry is a witness that almost always the object of studying psychiatrists was the psychotic forms of mental pathology and organic pathology, as the most clinically pronounced diseases, leading to the most rude forms of disadaptation and requiring urgent measures to treat and prevent complications. Naturally, they were often not noticed, ignored, and may not be interpreted as such many clinically not pronounced, amorphous, not typical, having a completely different stereotype of the non-psychotic forms of mental pathology. Today they are made to designate both border (small) mental disorders - neurosis, neurotic reactions and conditions, personal disorders, behavioral manifestations, disorders of adaptation, moomatoform disorders, psychosomatic disorders.
Adaptation disorders
Determination of adaptation disorders, etiology
Adaptation disorders (F43.2) on ICD-10 are characterized by the state of the subjective distress and emotional disorders arising during the adaptation period to a significant change in life or stressful event and creating difficulties for life. A stress event may disrupt the integrity of social relations of an individual or a system of social support and values \u200b\u200b(migration, refugee status) or make changes to life (admission to an educational institution, the beginning or end of professional activity, failure in achieving the desired goal, etc.). Individual predisposition, vulnerability matter, but adaptation disorder arises in response to a traumatic factor. So, for example, more often, adaptation disorders are found in persons with extremely high personal anxiety, with serious somatic diseases, disabled people, people who have lost their parents in early childhood or lack of maternal care. Adaptation disorders are most characteristic of adolescent age, which, however, does not exclude the possibility of their occurrence at any age. Most of the symptoms weaken with time without treatment, especially after the end of the stressor; At an option with a possible chronic flow, there is a risk of secondary depression, anxiety and abuse of psychoactive substances.
Diagnostics of adaptation disorders
Adaptation disorders are diagnosed in accordance with the state of the following criteria:
1) identified psychosocial stress that does not reach emergency or disaster scope, symptoms appear within a month;
2) individual symptoms (with the exception of delusional and hallucinatory), corresponding to the criteria of affective (F3), neurotic, stress and somatoform (F4) disorders and violations of social behavior (F91), not corresponding to any of them;
3) Symptoms do not exceed 6 months from the time of termination of stress or its consequences with the exception of protracted depressive reactions (F43.21).
Symptoms can vary by structure and severity. Disorders of adaptation depending on the manifestations dominant in the clinical picture are differentiated as follows:
F43.20 Short-term depressive reaction The transient state of easy depression, which is not more than a month;
F43.21 Prolonged depressive reaction is a slight depressive condition as a reaction to a protracted stressful situation, which is not more than two years;
F43.22 Mixed alarming and depressive reaction - presented both anxious and depressive symptoms, intensity not exceeding mixed alarm and depressive disorder (F41.2) or other mixed alarm disorders (F41.3);
F43.23 With the predominance of the violation of other emotions - symptoms has a variety of affect structure, anxiety, depression, concern, tension and anger are presented. Symptoms of alarm and depression can comply with the criteria for mixed alarm and depressive disorder (F41.2) or other mixed alarm disorders (F41.3), but their severity is insufficient for diagnosing more specific alarming or depressive disorders. This category should be used for children's reactions, where such signs of regressive behavior are additionally present, such as enuresis or sucking the finger;
F43.24 with a predominance of violation of behavior - disorder affects mainly social behavior, for example, aggressive or dissocial forms in the structure of the reaction of grief in adolescence;
F43.25 Mixed disorder of emotions and behavior - defining are both emotional manifestations and violations of social behavior;
F43.28 Other specific prevailing symptoms.
Differential diagnosis
The differential diagnosis of adaptation disorders should be carried out with a post-traumatic stress disorder, an acute reaction to stress, a short-term psychotic disorder, uncomplicated by severe loss. Post-traumatic stress disorder and acute reaction to stress is characterized by the fact that these diagnoses defines the unusual stress, which goes beyond normal human experiences, such as war, mass catastrophe, natural disaster, rape, taking hostage. A short-term psychotic disorder is characterized by hallucinations and nonsense. Uncomplicated severe loss arises to the expected death of a loved one or shortly after it; Professional or social activity worsens within the expected period, then spontaneously normalizes.
Treatment
For the treatment of adaptation disorders, preferred psychotherapy, which includes the study of the value of the patient's stressor, providing support, encourages the search for alternative ways to solve the problem, manifest sympathy. If the alarm prevails, then it is advisable to use biological feedback, relaxation and hypnosis techniques. Intervention during the crisis is aimed at promoting the patient in a rapid solution to the problem through the use of support methods, Suggestion, persecution, environmental modifications. If necessary, hospitalization is possible. Medicase therapy is shown in severe disorders. For treatment, anxiolytic agent or antidepressants can be applied depending on the type of disorder, but it is necessary to be careful to prevent dependence on the drug (especially when using benzodiazepines).
Somatoform disorders
The relevance of the problem of somatoform disorders
The problem of psychosomatic relations is the subject of discussions not only for psychiatry, but also for the general pathology of the person. The question of the influence of bodily sensations in the norm and pathology on the mental sphere and the development of various psychopathological phenomena is not doubtful. The presence of somatopsychiatric disorders is a reliable evidence of the existence of communication between the body and the psyche.
However, increasingly enriching clinical data suggests that changes in the mental sphere can cause corporal (including pathological) changes, thereby determining the development of so-called psychosomatic diseases.
The problem of somatopsychic pathology is quite detailed in the medical literature. As for psychosomatic violations, they are not studied enough and many issues relating to this problem are still far from permission. Among them, the problem of moomatoform disorders remains a particularly controversial and low-developed general media and psychiatric problem. The glances of clinicians on this problem are extremely contradictory, and often even diametrically opposite and mutually exclusive.
Timely diagnosis and adequate treatment of these states is put forward as the primary tasks of the public health system. Shifts that take place in modern psychiatry, dictate the relevance and necessity of a conceptual study of somatoform disorders. These shifts are determined, on the one hand, the displacement of the accent with the "large" to the "small" psychiatry, the steady growth of border mental pathology; On the other hand, there was a need to comprehend the accumulated data and information regarding masked depression, conversion disorders, hypochondria, psychegetative disorders that are actually the content of somatized mental disorders. Finally, the need to study moomatoform disorders is due to economic interests - the feasibility of additional, sometimes unjustified logistical expenses.
Definition
Somatoform disorders - a group of disorders characterized by the patient's constant complaints of a violation of its condition resembling a somatic disease; In this case, they do not detect any pathological process explaining their occurrence. Disorders are not due to other mental illness or abuse of psychoactive substances. If the patient has a somatic disease, data from the disease history, a somatic examination and laboratory tests cannot explain the cause and severity of complaints. The symptoms do not come up with intentionally, in contrast to artificially demonstrated disorders and simulation. Despite the fact that the emergence and preservation of symptoms is often closely associated with unpleasant events, difficulties or conflicts, patients are usually opposed to attempts to discuss the possibility of its psychological conditionality; This may occur even with distinct depressive and disturbing symptoms. To achievable the degree of understanding of the causes of symptoms is often disappointing and frustrating both for the patient and for the doctor.
Some researchers are convinced that somatoform symptoms are actually manifestations of hidden depression, and on this basis are treated with antidepressants, others believe that they are special conversion, that is, dissociative disorders, and therefore should be treated with psychotherapeutic methods.
The frequency of somatoform disorders is 0.1-0.5% of the population. More often, somatoform disorders are observed in women.
Somato classificationform disorders (on μb-10)
F45.0 somatized disorder.
F45.1 Untifferentiated somatoform disorder.
F45.2 Hypochondriatic disorder.
F45.3 Somatormal dysfunction of the vegetative nervous system.
F45.4 Sustainable somatoform pain disorder.
F45.8 Other somatoform disorders.
F45.9 Somatoform disorder Uncomfortable.
Separate syndromes occurring during somboform disorders
It is particularly possible to distinguish conversion syndromes, asthenic states, depressive syndromes, nervous anorexia syndrome, dysmorphophobia syndrome (dysmorfoomania), which are included in the structure of various moomatoform disorders.
Conversion syndromes. Characterized by a change or loss of any body function (anesthesia and paresthesia limbs, deafness, blindness, anosmia, pseudo-chase, paresis, choreiforous ticks, ataxia, etc.) as a result of psychological conflict or need, while patients do not realize what psychological The reason determines the disorder, so they cannot manage it arbitrarily. Conversion - transformation of emotional disorders into motor, sensory and vegetative equivalents; These symptoms in domestic psychiatry are usually considered within the framework of hysterical neurosis.
Asthenic states Refer to the most common in the practice of a wide profile physician. Fast depletion advances in these cases against the background of increased neuropsychiatric excitability. Among the complaints of a somatic nature with which the patient is drawn is primarily volatile and diverse headaches, sometimes the type of "neurasthenic helmets", but also tingling in the forehead and the back of the head, the feeling of the head of the head. Pains are enhanced with mental load and usually become more Heavy afternoon. Asthenical conditions can imitate symptoms inherent in one or another somatic disease. This is usually heartbeat, the lability of blood pressure, frequent urge to urination, dysmenorrhea, a decrease in libido, potency, etc.
Depressive syndromes Also found quite often (about half of the cases, the condition of somatoform patients qualifies as depressive). Of particular interest is the so-called somatzed (masked) depression.
Syndrome of nervous anorexia - Progressive self-restriction in food while preserving appetite for the purpose of weight loss due to conviction in an excessive completeness or fear of effort. This state is found mainly in female female in adolescence. Characteristic of the syndrome, expressed in its entirety, is the triad: a refusal of food, significant weight loss (about 25% of the premorbid mass), amenorrhea.
Dysmorphobia syndrome (dysforamia). This is a kind of hypochondriac syndromes, preferably found in adolescence (up to 80%). In dismortion phobic, there is a pathological conviction of either the presence of any physical disadvantage, or in the distribution of unpleasant odors. At the same time, patients fear that others observe these shortcomings, discuss them and laugh at them. For pronounced dysmertophobic syndrome typical Triad signs: the ideas of physical disadvantage, the ideas of the relationship, the depressed mood.
In connection with the conviction of the existence of an imaginary defect or in the presence of any minor physical disadvantage, with its excessive exaggeration, patients persistently turn to the doctors of various specialties - cosmetologists, dentists, endocrinologists, plastic surgeons.
For patients with dysmorphophobia, a tendency to dissimulate its condition is characterized. In this regard, it is important to note the presence of two characteristic symptoms that can be detected during the abrasing of patients and their relatives: these are the symptoms of the "mirror" (the close viewing of themselves in the mirror in the mirror in order to ensure the presence of physical disadvantage and try to find a person who hides this "defect ") And" photos "(the latter is considered as a documentary confirmation of the flawiness of its appearance, and therefore the photographing is avoided).
Clinic of somatoform disorders
Consider the most frequent variants of the flow of moomatoform disorders.
Somatized disorder. The main feature is the presence of multiple, re-arising and frequently modified somatic symptoms, which usually take place over a number of years preceding the patient's appeal to the psychiatrist. Most patients have undergone a long and difficult path, including primary and special medical service, during which negative surveys results were obtained and useless operations could be performed. Symptoms may relate to any part of the body or system, but most often meet gastrointestinal sensations (pain, belching, regurgitation, vomiting, nausea, etc.), as well as abnormal skin sensations (itching, burning, tingling, numbness, soreness etc.). Frequently, sexual and menstrual complaints.
Often detecting a clear depression and anxiety. It can justify specific treatment. The course of disorder is chronic and fluctuating, often combined with a long impaired social, interpersonal and family behavior. Disorder is much more common in women than men, and often begins at a young age.
The dependence or abuse of drugs is often discovered (usually seds or analgesics) as a result of frequent medication courses.
Somatormal dysfunction of the vegetative nervous system. Complaints are presented with patients in such a way as if they are due to the physical disorder of the system or body, which are mainly or completely under the influence of the autonomic nervous system, that is, a cardiovascular, gastrointestinal or respiratory system. (A genital system is partially related here. The most frequent and vivid examples relate to the cardiovascular system ("heart neurosis"), the respiratory system (psychogenic shortness of breath and the Ikota) and the gastrointestinal system ("neurosis of the stomach" and "nervous diarrhea"). Symptoms are usually two types, none of which indicates the physical disorder of the affected organ or system. The first type of symptoms on which the diagnosis is largely based, is characterized by complaints reflecting objective signs of vegetative arousal, such as heartbeat, sweating, redness and tremor. The second type is characterized by more idiosyncrazic, subjective and nonspecific symptoms, such as the sensations of fleeting pain, burning, gravity, voltage, feeling of inflating or stretching. These complaints belong to the patient to a specific organ or system (to which vegetative symptoms may also relate. A characteristic clinical picture is made up of distinct involvement of the vegetative nervous system, additional non-specific subjective complaints and permanent references of the patient to a certain body or system as the cause of its disorder.
Many patients with this disorder have guidance on the presence of psychological stress or difficulties and problems that are represented by the disorder. Nevertheless, a significant part of patients who meet the criteria for this disorder, unagreering psychological factors are not detected. In some cases, there may also be insignificant violations of physiological functions, such as hiking, flatulence and shortness of breath, but they themselves do not violate the basic physiological functioning of the relevant organ or system.
Chronic somatoform painful frustration. Among the causes of chronic somatoform pain, psychodunic - pain manifests itself as a way to achieve love, avoid punishment and reaping the guilt, the method of manipulating close. It is therefore a secondary benefit from this symptom. Presentation of pain can also be a way to hold next to the object of love or a peculiar reflex after a long period of somatic or neurological pain. In the etiology of pain, the central mechanisms associated with the level of endorphins are important.
General features of this disorder are: 1) the duration of the algopathic states at least 6 months; 2) the lack of confirmed as a result of special surveys of somatic pathology, which could determine the occurrence of pain; 3) the severity of pain complaints and the associated decrease in adaptation is significantly higher in cases of concomitant somatic pathology The expected consequences of somatic symptoms. Additional general features of algopathies are: 1) the absence of symptoms of endogenous disease (schizophrenia, TIR) and organic damage to the central nervous system; 2) comparability with observed in the somatic pathology painful sensations.
Pain often appears in combination with emotional conflict or psychosocial problems, regarded as a major cause. As a rule, headaches, back pain, breast, neck.
Hypochondriatic disorder. Despite the fact that hypochondria is one of the most private psychopathological phenomena, the issues of nosological assessment and the choice of adequate medical measures are not developed enough.
What is hypochondria? It is excessive, which does not have real life attention to its health, concern even a minor malaise or conviction in the presence of severe illness, violations in the bodily sphere or deformity.
Under the hypochondria, it is not just about anxious criminality as such, but on the relevant mental, intellectual processing of certain painful sensations by the somatic sphere. Often, the case ends with the design of the concept of a certain disease, followed by the struggle for his recognition and treatment. The psychopathological nature of the hypochondria is confirmed by the fact that when it combines it with a real somatic disease, the patient does not draw the latter and the share of the attention that pays imaginary disorder.
Hypochondriartic states are more often developing in a mature or old age, the same often in men and women.
The leading structural elements of the hypochondriac syndrome are primarily consistent with paresthesia - sensations of numbness, tingling, crawling goosebumps, etc., not caused by external stimuli. This is followed by psycholygia, due to some particular defeat, but as a consequence of the physiological increase in the painful threshold. These are ordinary pain without real bases, often multiple. Another such element is dentalgia, which differ more bizarre and peculiar character. For example, headaches here are already burning, shooting, penetrating, sting. This is followed by sensencestations - also arising spontaneously and extremely painful sensations that are not suitable for localization with specific anatomical formations. For sensencestations, novelty and variety of sensations are characterized; Patients are difficult to accurately describe them. And, finally, synesthesia are the sensations of unclear total physical disadvantage or ailments with peculiar, with difficulty description of the impairment of the motor sphere (unexpected physical weakness, shaking and uncertainty when walking, severity or emptiness in the body).
Differential diagnosis
Differential diagnosis of somatoform disorders is carried out with a whole group of diseases in which patients make somatic complaints. So a differential diagnosis of hypochondriad nonsense is usually based on attentive consideration of the case. Although the ideas of the patient remain a long and seem to be contradictory common sense, the degree of conviction is usually reduced to some extent and for a short time under the influence of the argument, soothe and holding new surveys. In addition, the presence of unpleasant and frightening physical sensations can be considered as a culturely acceptable explanation of the development and preservation of conviction in physical illness.
Differential diagnosis with somatic disorders is required, although usually patients fall to a psychiatrist after the doctors of the somatic profile. Nevertheless, the likelihood of independent somatic disorder in such patients is not lower than that of ordinary people at the same age.
Affective (depressive) and disturbing disorders. Depression and anxiety of varying degrees often accompany somatized disorders, but they should not be described separately except when they are sufficiently apparent and stable in order to justify their own diagnosis. The emergence of multiple somatic symptoms aged after 40 years may indicate the manifestation of primary depressive disorder.
It is also necessary to exclude dissociative (conversion) disorders, speech disorders, nail biting, psychological and / or behavioral factors associated with disorders or diseases classified in other categories, sexual dysfunction, not caused by organic disorders or diseases, ticks, houslie de la turrette syndrome , trichothillania.
Treatment
Therapy of somatoform disorders includes a wide range of medical and preventive measures requiring participation of both an interval practitioner and a psychiatrist and psychotherapist.
A tremendous practical significance has the fact that the corresponding mental disorders may not be recognized by the patients themselves or dissimulate. Patients are usually opposed to attempts to discuss the possibility of psychological conditionality of symptoms, even if there are clear depressive or disturbing manifestations. As a result, the baseline in the treatment of patients with somatoform disorders is currently psychotherapy. Virtually the entire spectrum of modern forms and methods of psychotherapy is used. Rational therapy, autogenic training, hypnotherapy, group, analytical, behavioral, positive, client-centered therapy, etc. However, despite the priority of psychotherapeutic correction, prevailing in the clinical picture of somategoetical components does not allow to do without medication therapy. In the initial period, even harshly, directive techniques do not allow to obtain a quick desired result, which ultimately compromises psychotherapy as a method.
Pharmacotherapy of somatoform disorders involves the use of a wide range of psychotropic drugs - primarily anxiolytic, as well as antidepressants, nootrops and neuroleptics. However, the use of psychotropic drugs in the clinic of somatoform disorders has its own characteristics. When prescribing psychotropic drugs, it is advisable to be limited to monotherapy using convenient drugs. Given the possibility of increased sensitivity, as well as the possibility of side effects, psychotropic drugs are prescribed in small (in comparison with used in "big" psychiatry) doses. The requirements also include minimal impact on somatic functions, body weight, minimum behavioral toxicity and teratogenic effect, the possibility of use during lactation, low probability of interaction with somatotropic drugs.
Conclusion
The pronounced clinical pathomorphosis of moomatorm disorders themselves, a significant expansion of their classification reference and an increase in the specific gravity of somatic pathology flowing with border mental disorders, requires revision and refinement of differential diagnosis criteria and creates prerequisites for the development of new diagnostic and therapeutic approaches. Timely detection and adequate diagnosis of somatoform disorders is crucial for successful therapy and a favorable disease forecast.
In this regard, it is advisable to integrate the system of psychotherapeutic assistance in general-general treatment-and-prophylactic structures, the opening of psychosomatic departments in the structure of general general hospitals. It is also necessary to emphasize the important role of improving the knowledge of the general medical network doctors. For general practitioners, teaching the fundamentals of medical ethics, deontology and psychotherapy should be provided, for psychotherapy doctors - in-depth professional training. The development of special training programs on specific issues of psychosomatic pathology (clinic, diagnosis, therapy), conducting thematic conferences and seminars, organization of advanced training courses is very relevant.
BIBLIOGRAPHY
1. TB Dmitrieva. "Clinical psychiatry. Guide for doctors and students "1998.
2. G.I. Kaplan B.J. Sedo. "Clinical psychiatry. From Sinopsis on psychiatry in 2 volumes "1994.
3. Journal of Neurology and Psychiatry named after S.S. Korsakov.
4. MKB-10. Clinical classification.
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Despite the bondability of vegetative dysfunction and often masked character of emotional disorders, the basic method of treating adaptation disorders is psychopharmacological treatment. The therapeutic strategy must be built depending on the type of dominant disorder and the degree of its severity. The choice of drug depends on the degree of severity of the level of anxiety and the duration of the disease.
If painful symptoms exist short time (up to two months) and slightly violate the functioning of the patient, they can be used both drug (anxiolytic therapy) and irritable methods. Nercomer therapy is, first of all, the possibility of expressing patients with their fears in the situation of psychological support, which the doctor can have. Of course, the professional assistance of a psychologist can activate the adaptation methods characteristic of the patient.
Medicinal treatments include primarily tranquilizing drugs. Benzodiazepine anxiolitics are used to relieve acute alarm symptoms and more than 4 weeks should not be applied due to the threat of the formation of dependence syndrome. With a short-term subsidarial or soft alarming disorder of adaptation, plant soothing fees or preparations based on them, antihistamines (hydroxyzine) are used. For many years, Valerian has been used in traditional medicine due to hypnotic and sedative effects and to date remains very popular medicine. Preparations containing valerian and additional phyto extracts, enhance the anxiolytic effect of Valerians, were particularly successful. Wide application found a drug percene, which contains, in addition to Valerians, Melissa and Mint extract, which enhances the anxiolytic effect of Valerians and adds antispasmodic effect. Especially well established itself in the treatment of subsindrome alarm and soft alarm disorders percean-forte, containing 125 mg of valerian extract in a capsule against 50 mg in a tablet form, thanks to which Persen-Forte provides a high and fast anxolytic effect. The spectrum of the application of Persen-Forte in the practice of clinician is extremely wide - from use in monotherapy for the treatment of subsidommal and soft disturbances to a combination with antidepressants for anxiety leveling during anxiously depressive disorders. There are no clear recommendations on the duration of the therapy of soft and subsidarial alarm syndromes. Nevertheless, most studies have proven the benefits of long course therapy courses. It is believed that after the reduction of all the symptoms, at least 4 weeks of medicinal remission should pass, after which an attempt is made to cancel the drug. On average, treatment with sedative vegetable fees is 2-4 months.
Preparations of the first queue of choice for the treatment of chronic alarm disorders are selective inhibitors of serotonin reverse seizure (SSRS). In case of adaptation disorders, the question of the purpose of the SSIOS is risks in the case of the risk of disorder (progression of symptoms of more than three months) and / or risk of transition of adaptive disorder in the clinical forms of psychopathology. In addition, the indication for the appointment of antidepressants is an adaptation disorder with an alarm-depressive mood or the dominance of depressive mood.
Many drugs used to treat mood disorders, anxiety and sleep disorders can be poorly to be patients due to side effects, which ultimately level their effectiveness. Official preparations of vegetable origin, having significantly less side effects, can be considered as an alternative therapy or used to enhance the effectiveness of prescription drugs (in particular, in the intolerance to tranquilizers and antidepressants).
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